<H1>Welcome to NIIT's Online Test Booking Facility for certification exams conducted through Prometric.</H1>
<p> * Indicates mandatory information</p>
    <form>
   	  <div class="leftbox">
    <h1>sign in information</h1>
       	  <div class="name">Username: * <span>(Use for sign in)</span></div>
          <input name="" type="text" class="txt_input" />
          <div class="name">Password: *</div>
          <input name="" type="text" class="txt_input" />
          <div class="col14">
          <div class="name">Title: *</div>
          <select name="select" class="lst_choice14" id="select">
            <option>Click one ...</option>
            <option>Mr</option>
            <option>Ms</option>
            <option>Mrs</option>
            <option>Dr</option>
            <option>Prof</option>
          </select>          
          </div>
        <div class="col142">
          <div class="name">Gender: *</div>
          <select name="select" class="lst_choice14" id="select">
            <option>Click one ...</option>
            <option>Male</option>
            <option>Female</option>
          </select>
          
          </div>
          <div id="clearone"></div>
          <div class="name">First name: *</div>
          <input name="" type="text" class="txt_input" />
          <div class="name">Middle name:</div>
          <input name="" type="text" class="txt_input" />
          <div class="name">Last name: *</div>
          <input name="" type="text" class="txt_input" />
        </div><!--endleftbox-->
     		
      	<div class="rightbox">
          <h1>contact information </h1>
  		  	<div class="name">Email address: * <span>(Confirm email will be send to this email)</span></div>
              	<input name="" type="text" class="txt_input" />
                <div class="col16">
                  <div class="name">Day of Birth: *</div>
                  <select name="select" class="lst_choice16" id="select">
                    <option>Click one ...</option>
                    <option>1</option>
                    <option>2</option>
                    <option>3</option>
                    <option>4</option>
                    <option>5</option>
                    <option>6</option>
                    <option>7</option>
                    <option>8</option>
                    <option>9</option>
                    <option>10</option>
                    <option>11</option>
                    <option>12</option>
                    <option>13</option>
                    <option>14</option>
                    <option>15</option>
                    <option>16</option>
                    <option>17</option>
                    <option>18</option>
                    <option>19</option>
                    <option>20</option>
                    <option>21</option>
                    <option>22</option>
                    <option>23</option>
                    <option>24</option>
                    <option>25</option>
                    <option>26</option>
                    <option>27</option>
                    <option>28</option>
                    <option>29</option>
                    <option>30</option>
                    <option>31</option>
                  </select>          
              </div>
              <div class="col162">
                  <div class="name">Month of Birth: *</div>
                  <select name="select" class="lst_choice16" id="select">
                    <option>Click one ...</option>
                    <option>1</option>
                    <option>2</option>
                    <option>3</option>
                    <option>4</option>
                    <option>5</option>
                    <option>6</option>
                    <option>7</option>
                    <option>8</option>
                    <option>9</option>
                    <option>10</option>
                    <option>11</option>
                    <option>12</option>
                  </select>          
              </div>
              <div class="col162">
                  <div class="name">Year of Birth: *</div>
                  <select name="select" class="lst_choice16" id="select">
                    <option>Click one ...</option>
                    <option>1996</option>
                    <option>1995</option>
                    <option>1994</option>
                    <option>1993</option>
                    <option>1992</option>
                    <option>1991</option>
                    <option>1990</option>
                    <option>1989</option>
                    <option>1988</option>
                    <option>1987</option>
                    <option>1986</option>
                    <option>1985</option>
                    <option>1984</option>
                    <option>1983</option>
                    <option>1982</option>
                    <option>1981</option>
                  </select>          
              </div>
              <div id="clearone"></div>
              
              <div class="name">Address Type: *</div>
              <select name="select" class="lst_choice" id="select">
                <option>Click one ...</option>
                <option>Home</option>
                <option>Office</option>
       	  </select>
            
            <div class="name">Address: *</div>
            <input name="" type="text" class="txt_input" />
            
<div class="col14">
                  <div class="name">Country: *</div>
                  <select name="select" class="lst_choice14" id="select">
                    <option>Click one ...</option>
                    <option>1</option>
                    <option>2</option>
                    <option>3</option>
                    <option>4</option>
                    <option>5</option>
                    <option>6</option>
                    <option>7</option>
                    <option>8</option>
                    <option>9</option>
                    <option>10</option>
                    <option>11</option>
                    <option>12</option>
                    <option>13</option>
                    <option>14</option>
                    <option>15</option>
                    <option>16</option>
                    <option>17</option>
                    <option>18</option>
                    <option>19</option>
                    <option>20</option>
                    <option>21</option>
                    <option>22</option>
                    <option>23</option>
                    <option>24</option>
                    <option>25</option>
                    <option>26</option>
                    <option>27</option>
                    <option>28</option>
                    <option>29</option>
                    <option>30</option>
                    <option>31</option>
                  </select>          
              </div>
<div class="col142">
                  <div class="name">State: *</div>
                  <select name="select" class="lst_choice14" id="select">
                    <option>Click one ...</option>
                    <option>1</option>
                    <option>2</option>
                    <option>3</option>
                    <option>4</option>
                    <option>5</option>
                    <option>6</option>
                    <option>7</option>
                    <option>8</option>
                    <option>9</option>
                    <option>10</option>
                    <option>11</option>
                    <option>12</option>
                  </select>          
              </div>
              
              <div id="clearone"></div>
<div class="col14">
                  <div class="name">City: *</div>
                  <select name="select" class="lst_choice14" id="select">
                    <option>Click one ...</option>
                    <option>1996</option>
                    <option>1995</option>
                    <option>1994</option>
                    <option>1993</option>
                    <option>1992</option>
                    <option>1991</option>
                    <option>1990</option>
                    <option>1989</option>
                    <option>1988</option>
                    <option>1987</option>
                    <option>1986</option>
                    <option>1985</option>
                    <option>1984</option>
                    <option>1983</option>
                    <option>1982</option>
                    <option>1981</option>
                  </select>          
              </div>
          <div class="col142">
          <div class="name">Pin code: *</div>
          <input name="" type="text" class="txt_input14" />       
          </div>
          <div id="clearone"></div>
          <div class="col14">
          <div class="name">Phone Type: *</div>
          <select name="select" class="lst_choice14" id="select">
            <option>Click one ...</option>
            <option>Male</option>
            <option>Female</option>
          </select> 
          </div>
          <div class="col142">
          <div class="name">Phone number: *</div>
          <input name="" type="text" class="txt_input14" />       
          </div>
          <div id="clearone"></div>
          <div class="col14">
          <div class="name">Fax Number: </div>
          <input name="" type="text" class="txt_input14" />
          </div>
          <div class="col142">
          <div class="name">Yahoo Messenger ID: </div>
          <input name="" type="text" class="txt_input14" />       
          </div>
          <div id="clearone"></div>
      	</div><!--endrightbox-->
        
        
    	<div id="clearone"></div>
         <div class="name"><input name="" type="checkbox" value="" /> I accept the Terms & Conditions and agree that I have read the Rules & Regulations mentioned on the site.</div>
    	<div class="nav_btn">
            <a href="#" class="rightbtn"><input name="" type="submit" value="Save &amp; Submit" /></a>
            <a href="#" class="leftbtn"><input name="" type="reset" value="Reset" /></a>
            <div id="clearone"></div>
        </div>
    </form>
